Perinatal Depression Patients Want Flexibility in Therapy

PHOENIX — Flexibility in scheduling would help depressed women access cognitive-behavioral therapy during or just after pregnancy, a survey of 24 women found. A little more respect would be nice too, respondents said.

Results of the qualitative survey informed a revision of a cognitive-behavioral treatment manual that will be tested in a randomized, controlled trial with 60 women comparing the revised therapy model with treatment as usual, Heather A. Flynn, Ph.D., said at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

She and her associates used the Edinburgh Postnatal Depression Scale to screen 274 pregnant or postpartum women in the waiting rooms of five obstetrics clinics. The Structured Clinical Interview for DSM Disorders identified 24 of these women, who completed a questionnaire about their preferences for receiving cognitive-behavioral therapy, with major depressive disorder or minor depression. The women said they would prefer to get CBT in an obstetrician's office or at home by telephone. Postpartum women said that having child care available at the clinic would be a big help. “We're actually doing that now,” said Dr. Flynn, an assistant professor of psychiatry at the University of Michigan, Ann Arbor.

All 24 women spontaneously reported that they have felt judged, disrespected, or stigmatized by health care workers. “Women did not feel that they were listened to” as they tried to get help, she said.

The women did not acknowledge that what they were experiencing was depression, however, and did not want therapy to be presented as treatment for depression. “The way you present treatment is very important,” Dr. Flynn suggested.

The investigators preliminarily tested an eight-session program of CBT in 12 patients, all of whom showed up for the first three sessions that were conducted with prenatal care visits at the obstetrics clinic. Overall, half of all sessions needed to be rescheduled in order for 78% of the sessions to be completed, she reported. One woman stopped therapy; three completed the eight sessions; and eight patients are still in therapy.

The 11 patients who completed or who continue therapy have benefited from treatment, Dr. Flynn said, and they report high satisfaction with the program. “The more flexible we are, the more likely that we're going to retain these women in therapy,” she said.

Several previous studies found that approximately 75% of women with depression during pregnancy or the postpartum period go undiagnosed or untreated, Dr. Flynn said. One of the main barriers seems to be difficulty in accessing treatment. “The treatments are probably fine. It's just that women are not accessing them,” she said. “They may or may not be ambivalent about treatment. It's just that they have chaotic lives.”

Most of the women in her pilot studies had incomes below the poverty line, and a few were homeless. Many lacked transportation. “We need to be as flexible as possible to accommodate these women,” she said.